Population Coverage to Reach Universal Health Coverage in Selected Nations: A Synthesis of Global Strategies.

Background
This study aimed to provide tailored transferrable lessons for expanding population coverage through a descriptive lens by reviewing the population coverage policies, reforms and strategies in selected nations.


Methods
In this comparative short communication, 14 countries with different status of population coverage and political economy that had successful experiences with coverage expansion were selected and categorized in four groups to study their approaches to reach Universal Health Coverage (UHC).


Results
Although each country needs to tailor its policies and reforms based on its own contextual factors, the legal right of citizens to social security and health protection are enshrined in most countries' Constitution. Some countries adapted political and economic reforms to evolve their Social Health Insurance schemes. National laws to push governments to adapt UHC as a national strategy for ensuring that every resident is enrolled in health insurance schemes are key policies to reach UHC.


Conclusion
A series of reforms are required to provide total population coverage through various approaches. To create an effective insurance coverage, physical merger of all insurance funds is not necessarily required. Further, the share of GDP for health is not a definite indicator to reach UHC. Finally, strong political commitment and citizens' participation are the key issues in reaching UHC, while considering the poorest, remote and neglected population really matters.


Introduction
To achieve the 2030 agenda for Sustainable Development, countries need a comprehensive strategy to invest in health, education, nutrition, environment, and security for all. These goals cannot be met without ensuring universal access to affordable and high-quality health services. Goal three of the sustainable development indicates achieving health and well-being at all ages. Universal Health Coverage (UHC) is a key target of SDGs, urging all countries to be wellpositioned by 2030 to ensure universal health coverage for all citizens (1). WHO recommends UHC aiming to provide universal and equitable access to health services for ensuring improved health outcomes. UHC consists of three interrelated components: (a) the full spectrum of health services according to need; (b) financial protection (2) from direct payment for health services when consumed; and (c) coverage for the entire population (2). Population health coverage is defined as access to needed health services of good quality (3). Providing effective population coverage in UHC requires several steps including identifying poor and unprotected groups, empowering and informing them regarding their benefits, and ensuring their physical and financial access to required healthcare services (4). Although universality suggests that all people are ideally covered, the World Health Report of 2010 noted that none of the high-income countriesthat are commonly said to have achieved universal coverage-actually cover 100% of the population for 100% of the services available and for 100% of the cost and with no waiting lists (5). UHC is not a far-reaching goal for developing countries. Countries like Turkey, Mexico, Thailand, and Chile have had great ambition of UHC and their leaders developed national plans and strategies to prioritize and implement UHC (6).
The overall aim of this study was to provide tailored transferrable lessons for expanding population coverage towards UHC in various settings.

Methods
In this descriptive-comparative study, we reviewed the strategies and policies within 14 selected countries that had successful experiences with coverage expansion and studied their current population coverage policies and strategies. Included countries were categorized into four groups based on their various status of population coverage, political economy, economic situation and political commitment towards UHC (Table 1). We searched the official websites of WHO and World Bank. We sought for publicly available reports and documents from the year 2000 until Nov 2016 and used general terms representing "population coverage" and "universal health coverage". In addition, we searched the Internet search engine Google to find additional documents and reports and enhance the comprehensiveness of our search. The reference lists of all selected documents were also scanned. Finally, among 47 reports and documents, 25 were selected and re-viewed to extract related information about their policies, strategies and rules to expand population coverage to reach UHC. We describe countries' approaches to reach universal population coverage in the following section and then discuss the transferrable lessons.

Results
The legal right of citizens to social security and health insurance are preserved in most countries' Constitution. Some countries adopted political and economic reforms to evolve their Social Health Insurance schemes. Increasing the pro-portion of the population enrolled in health insurance is a key policy goal for the governments. Other countries adopted UHC as a national strategy to ensure that every resident gets access to affordable health care (7)(8)(9)(10)(11)(12)(13)(14)(15). The main strategies, plans and policies are described in Table 2.  (21). In 2015, to fulfill the constitutional obligation of the right to health, White paper on the implementation of National Health Insurance (NHI) to achieve UHC was published (7,16). According to the paper, NHI will extend coverage to all South Africans with the priority of the poor and vulnerable groups. Private insurance covers 17% of the population (22 Japan 126 573 10.2 13.9 0.903 Health insurance system consists of two complementary structure employment-based health insurance and residence-based health insurance. Employees of large companies and employees of small to medium companies are covered by the employment-based scheme, which receives no subsidy and 16.4% subsidies respectfully. Residence-based mandatory health insurance programs cover the self-employed, non-employed and pensioners below 75, which gets 50% subsidies. There is a health insurance program for elderly. People at the age of 40 and over are mandated to enroll in long-term care insurance (1). England 64 716 9.1 9.7 0.909 The NHS provides universal access to healthcare to all residents, the entitlement is based on clinical need, not on ability to pay. The Consumer demand for private health insurance is growing rapid (24). In 2015, about 11% of the England population had private voluntary health insurance that is less than many OECD countries. First employees of large corporations with more than 500 workers were covered and then this coverage was extended to smaller firms. Medical Aid Program began for the poor, school teachers and government employees. Universal health coverage was achieved by expansion of health insurance to the rural self-employed and the urban self-employed in 1989. The first priority has been given to population coverage rather than the scope and depth of service coverage (28).

Discussion
This study identified various pathways taken by countries belonging to diverse sociopolitical economies to reach universal population coverage, resulted in various UHC stages. Moving toward universal coverage is a procedure involves a range of challenges and points to consider. The importance of population coverage to achieve UHC is clear. Population coverage is a gradual, incremental and contextual-based process that cannot be achieved overnight. To move forward, a sequence of other reforms is essential. The experiences of Turkey and BRICS countries show that moving towards UHC is not fast and requires some fundamental problems in the health systems to be resolved. There is no single and magic formula that fits all settings to expand coverage. Hence, countries should adapt policies and measures according to their contextual factors. As a fundamental issue under discussion in many countries, physical merger of various insurance funds are not neces-sarily required to reach UHC. For instance, Thailand reached UHC without physical merger of the existing three main funds. To reach UHC, a clear statement of objectives and focus on visible outcomes is essential, followed by monitoring and evaluation of actions to complete the procedure. Foremost, total expenditure on health as a percentage of GDP is not necessarily a good indicator of reaching UUC. Thailand is an excellent example here. Thailand spent about 4.1% of its GDP on health (29), which is considerably lower than many other middle and high-income countries that spend around 7%-11% of its GDP on health. Besides, strong political commitment and support of influential stakeholders, as well as citizens' participation, are the key issues to take sustainable policies and plans towards UHC. Brazil emphasized on health as a right of citizens and showed high level of engagement by the civil society and high commitment of relevant authorities to adapt related health policies to change the pathway, development, and implementation of its population coverage's programs.

Conclusion
Many countries have accepted UHC as a part of 2030 agenda and have begun to expand population coverage to fulfill this goal. The poorest populations who live in rural and remote areas often face the highest financial burden and health risks and are in a greater need for more services. Contextual-based and tailored interventions and policies are essential to expanding population coverage towards paving the way to UHC. Looking at the experience of various countries summarized in this article may provide practical transferrable lessons for many countries around the globe that are planning to expand population coverage to reach UHC by 2030.

Ethical considerations
Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.